FRESNO STATE ON THE MOVE
REGISTRATION FORM
Name
Email
Phone
I have a team leader:
I would like to be placed on a team
I would like to be added to the Wellness ListServ to receive program
updates and information on upcoming events.
SELF-ASSESSMENT PRE-TEST
1.During a typical week, how many times do you walk for at least 10 minutes at a time?
__________
2.During those times, how long do you typically spend walking? _______hours _______
minutes
3.During a typical week, how many times do you perform vigorous (heavy lifting, digging,
running) or moderate (carrying light loads, bicycling at regular pace) activity for over 10
minutes? DO NOT INCLUDE WALKING. __________
4.During those times, how long do you typically spend in those activities? _____ hours ______
minutes
 Please rate your energy level over
 What are you wellness goals?
the last two weeks.
(check all that apply)
Low
Lose weight
Somewhat low
Increase activity level
Medium
Manage stress better
Somewhat high
Eat a healthier diet
High
Other (please list)
Please return your completed Registration Form to the Fresno State On the Move table at the Wellness Expo on
September 19, the Kick-Off Walk on September 25, or by email ([email protected]) or mail (M/S LS86)
to Katie Williamson by September 28 at 5 pm
CALIFORNIA STATE UNIVERSITY, FRESNO
GENERAL RELEASE AND WAIVER OF LIABILITY
In consideration of California State University, Fresno permitting me to participate in the activity described below, and to
engage in all activities related to the activity, the undersigned, for himself/herself and his/her personal representatives,
assigns, heirs and next of kin, or any of them:
1. Hereby Releases, Waives, Discharges and Covenants Not to Sue California State University, Fresno; The California State
University Fresno Foundation, Inc.: The California State University, Fresno Association, Inc; The California State
University Fresno Athletic Corporation, Inc.; The Board of Trustees of The California State University, and the State of
California and their trustees, officers, employees , volunteers and agents (hereafter, “Releasees”), from all liability to the
Undersigned, his/her personal representatives, assigns, heirs and next of kin for all losses or damage and any claim or
demands therefore, on account of injury to the person or property or resulting in death of the Undersigned, whether
caused by the negligence of Releasees or otherwise while the Undersigned is participating in the activity.
2. Hereby Agrees to Indemnify and Save and hold Harmless the Releasees and each of them from any and all losses,
liabilities, damages, costs, actions, claims or demands of any kind and nature whatsoever which may arise out of or in
connection with the Undersigned’s participation in the activity, whether caused by the Releasees or otherwise.
ACTIVITY: Fresno State On The Move Physical Activity Program
The Undersigned is fully aware of the risks and hazards inherent in the program and hereby voluntarily elects to participate in
said program with the knowledge of the danger involved. The Undersigned hereby voluntarily assumes all risk of loss,
damage, injury, or death that may be sustained by the Undersigned while participating in the activity.
The Undersigned expressly agrees that the foregoing release, Waiver and Indemnity Agreement is intended to be as broad
and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed
that the balance shall, notwithstanding, continue in full legal force and effect.
THE UNDERSIGNED HAS CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTANDS ITS
CONTENTS. THE UNDERSIGNED IS AWARE THAT THIS IS A RELEASE OF LIABILITY AGAINST THE
RELEASEES AND SIGNS IT OF HIS/HER OWN FREE WILL.
DATED:
Signature of Participant
Printed Name of Participant
PeopleSoft ID Number